Margaret McCartney: Trust the patient.

Each year surveys tell us that doctors are the most trusted UK professionals, well above journalists and politicians. Trust can be quick or slow to grow, conditional, and tentative. But trust is best when it’s experiential, laid down in aliquots of conversation, gesture, and thinking silence, and built up through repeated contact over time. A trusting relationship doesn’t mean perfection. Rather, trust should encompass the truth that all human action is liable to error. This means acknowledging human flaws; how we react to error and try to prevent it are indicators of whether trust is deserved. Many doctors have recently discussed the desire of patients and their carers or families to record conversations with them, either openly or secretly. Recording these consultations would seem liberating—a good way for patients to be able to listen again, share complex options with others, and reflect on or reconsider their choices. Yet the overwhelming reaction of many doctors is a fear that the recordings will be used against them. Fear that their words will be found deficient, that they will be criticised for the tone of their voice, for missing out something important, for not being exam perfect. Will the consultation be posted online to mock, passed to lawyers to sue, or sent to the General Medical Council to complain? In other words, trust is lacking, but now it is doctors who wonder whether they can trust their patients. Why is this important? Uncertainty is the natural state of medicine, and practising cover-my-backmedicine is miserable. In fear of litigation we order too many tests—protecting doctors but exposing patients to the risk of incidentalomas and treatment of no benefit. We become afraid to use time as a diagnostic safety net, worried about criticisms of late diagnosis. And we are more afraid of having to justify why we did not encourage a prescription to be taken rather than why we offered informed choice. Covering backs means that self protection trumps the fair use of community resources. I’ve written before about my fear that doctors and patients are becoming divided rather than united by our shared concerns. There’s a colossal difference between patients recording consultations to help them and their family, and patients doing so to search for imperfection, to complain and sue. Trust is a two way street. We need doctors who are worthy of it; we also need to know that the relationships we have with our patients contain the same trust.